Benha University Hospital, Egypt
Aboubakr Elnashar
30% of infertile couples.
Aboubakr Elnashar
1. Infection
PID
Appendicitis,
2. Endometriosis
3. Previous tubal surgery
4. Pelvic adhesions
5. Congenital anomalies of t...
PID
one, two, or three episodes:
12%, 23%, and 54%, respectively tubal disease
Chlamydial infections:
major cause of tub...
Aboubakr Elnashar
Aboubakr Elnashar
European Society of Human Reproduction &
Embryology (ESHRE) (2000)
Infertility testing should be classified into 3
groups ...
II. Tests that are not consistently associated with
pregnancy:
Post-coital test,
Antisperm antibody tests
Zona-free hamste...
1. Hysterosalpingography
The most commonly performed screening test for
tubal patency.
Advantages:
1.Position of tubal oc...
4. Relatively cheap & simple.
5. HSG is in agreement with the laparoscopic
findings approximately two thirds of the time.
...
HSG findings:
1. Mucosal rugae
Present:
favorable prognostic factor for subsequent
pregnancy: 60% PR
Absence:
severely da...
Aboubakr Elnashar
2. Periadnexal adhesions
 An irregular distribution of loculated contrast
medium around the fimbriated end of the tube
N...
Aboubakr Elnashar
Disadvantages
1. The pelvis including the ovaries is exposed
to radiation: significant problem if the patient
had an earl...
3. Intravasation
Network of streaklike opacities adjacent to
the uterine cavity that extend toward the
pelvic side walls ...
4. False occlusion: 12.5%
false patency: 11%
{high incidence of false cornual obstruction}
two separate tubal studies shou...
Proximal Tubal Obstruction
Fibrosis obliteration & SIN 40%
Endometriosis & Cornual polyp 10%
Cornual spasm 20%
Amorph...
The optimal contrast medium
Oil-soluble Water-soluble
Uterine image Sharp Less sharp
Ampullary rugae Difficult to defin...
Mechanisms by which HSG may enhance fertility
1. Mechanical lavage of a partially obstructed tube,
2. Stimulation of the ...
Contraindications
Absolute
Possible pregnancy
History of acute PID.
Relative
History suggestive of PID
Recent uterine ins...
The risk for PID after HSG
1% to 3%
Routine antibiotic prophylaxis
Patients at risk for acute PID
Doxycycline: 100 mg ...
2. Sonohysterosalpingography
An ultrasound contrast dye or saline (10-40 ml) is
injected into the uterus through the cerv...
HS-contrast-US
Free fluid collection in the cul-de-sac following
successful demonstration of oviductal patency.
Oviductal ...
Hydrosalpinx
well-constrained fluid
accumulation in the adnexae.
In some cases, adhesions
between the oviduct and ovary
ma...
3. Laparoscopy
Indication
1. Abnormal HSG or
2.History or symptoms suggestive of pelvic disease.
Normal HSG or no histor...
Laparoscopy may reveal
minimal or mild endometriosis or
peritubal adhesions.
Surgery or medical treatment has not been p...
Advantage
1. Direct visualization of the pelvic anatomy.
2. Determine:
appearance of the fimbria
presence of periadnexal ...
Laparoscopic findings:
1. Postinfection tubal disease .
The most common
Pelvic adhesions, phimotic fimbria, hydrosalpinge...
Aboubakr Elnashar
 ASRM classifications of
adnexal adhesions,
distal tubal occlusion, and
endometriosis is based on laparoscopic findings a...
Disadvantages
1. An invasive test requiring a GA with its
associated risk
2. Small risk of visceral damage on insertion
3...
Hysteroscopy
Not an initial investigation unless clinically indicated
{effectiveness of surgical treatment of uterine
abno...
4. Transvaginal hydrolaparoscopy (THL)
±Method of choice for the clarification of
mechanical infertility factors in sympt...
5. Chlamydia antibody testing (CAT)
HSG is more accurate than CAT in predicting tubal
disease
(Elnashar et al,2000).
If ...
Aboubakr Elnashar
Management strategy
The role of surgery (open laparotomy or extensive
laparoscopic surgery) for the treatment of tubal fa...
IVF
Main player for treatment of tubal factor.
Indication
1. Moderate to severe tubal disease
A. Distal tubal occlusion...
•Post-ligation:
open microsurgery
•Distal Tubal disease:
Mild: Laparoscopic surgery
Moderate to severe: IVF
•Proximal tuba...
British Fertility Society Classification of
Tubal disease
Minor
Proximal
occlusion without
tubal fibrosis
Distal occlusion...
Aboubakr Elnashar
Peritubal adhesions
with healthy
endosalpinx
•Laparoscopic
surgery
•IVF
Chronic salpingitis
• IVF
• Salpingectomy
before I...
1. Laparoscopic Surgery:
Fimbrioplasty
Lysis of fimbrial adhesions or the dilation of fimbrial
strictures.
Neosalpingost...
Aboubakr Elnashar
Aboubakr Elnashar
2. Transcervical cannulation of the proximal
fallopian tube
Methods
hysteroscopy
fluoroscopy, or
sonography
Results
succ...
Selective salpingography plus tubal
catheterisation, or hysteroscopic tubal
cannulation
Proximal tubal disease
If pregnanc...
3. Microsurgical reanastomosis of the fallopian
tubes:
 Patients who want to become pregnant after
having undergone tubal...
4. In Vitro Fertilization
Indications
1. Tubal factor infertility,
2. male factor infertility,
3. endometriosis
4. unexpl...
IVF or ICSI:
IVF should be the initial treatment of choice
(Aboulghar et al,1996; Bukulmez et al,2000).
{No significant di...
Bilateral salpingectomy or tubal sterilization
for women undergoing IVF who have
1. Hydrosalpinges, which adversely affec...
Hydrosalpinges
salpingectomy, preferably by laparoscopy, before
IVF treatment
{improves the chance of a live birth}.
Abou...
Benha University Hospital, Egypt
Email:elnashar53@hotmail.com
Aboubakr Elnashar
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Tubal factor infertility

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Tubal factor infertility

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Tubal factor infertility

  1. 1. Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2. 30% of infertile couples. Aboubakr Elnashar
  3. 3. 1. Infection PID Appendicitis, 2. Endometriosis 3. Previous tubal surgery 4. Pelvic adhesions 5. Congenital anomalies of the tubes Aboubakr Elnashar
  4. 4. PID one, two, or three episodes: 12%, 23%, and 54%, respectively tubal disease Chlamydial infections: major cause of tubal factor infertility Ruptured appendix: 5X tubal disease No identifiable risk factors 50% of patients with documented tubal factor infertility Aboubakr Elnashar
  5. 5. Aboubakr Elnashar
  6. 6. Aboubakr Elnashar
  7. 7. European Society of Human Reproduction & Embryology (ESHRE) (2000) Infertility testing should be classified into 3 groups depending on correlation with pregnancy rates I. Tests that have an established association with pregnancy: 1. Conventional semen analysis 2. Tubal patency tests, 3. Tests of ovulation Aboubakr Elnashar
  8. 8. II. Tests that are not consistently associated with pregnancy: Post-coital test, Antisperm antibody tests Zona-free hamster egg penetration test III. Tests that have no association with pregnancy: Endometrial biopsy Varicocele assessment Chlamydia testing Aboubakr Elnashar
  9. 9. 1. Hysterosalpingography The most commonly performed screening test for tubal patency. Advantages: 1.Position of tubal occlusion 2. unilateral patency can be dd from bilateral patency. 3. Degree of damage to tubal endothelium 4. Peritubal adhesion. 5. uterine cavity Aboubakr Elnashar
  10. 10. 4. Relatively cheap & simple. 5. HSG is in agreement with the laparoscopic findings approximately two thirds of the time. Sensitivity: 73 Specificity: 83% High specificity makes it useful in ruling in tubal obstruction Aboubakr Elnashar
  11. 11. HSG findings: 1. Mucosal rugae Present: favorable prognostic factor for subsequent pregnancy: 60% PR Absence: severely damaged tubal epithelium: 7.3% PR Aboubakr Elnashar
  12. 12. Aboubakr Elnashar
  13. 13. 2. Periadnexal adhesions  An irregular distribution of loculated contrast medium around the fimbriated end of the tube Not reliable in evaluation of peritubal adhesions Aboubakr Elnashar
  14. 14. Aboubakr Elnashar
  15. 15. Disadvantages 1. The pelvis including the ovaries is exposed to radiation: significant problem if the patient had an early pregnancy. 2. Abdominal pain which peaks 5 min after starting & usually settles within 30 min. Aboubakr Elnashar
  16. 16. 3. Intravasation Network of streaklike opacities adjacent to the uterine cavity that extend toward the pelvic side walls and subsequently migrate in a cephalad direction. Early detection of intravasation: minimizes complications. Whenever there is evidence of intravasation, injection should be discontinued immediately, regardless of the contrast medium used. Aboubakr Elnashar
  17. 17. 4. False occlusion: 12.5% false patency: 11% {high incidence of false cornual obstruction} two separate tubal studies should be performed before the diagnosis of proximal tubal obstruction is confirmed. (Holz et ao, 1997) Aboubakr Elnashar
  18. 18. Proximal Tubal Obstruction Fibrosis obliteration & SIN 40% Endometriosis & Cornual polyp 10% Cornual spasm 20% Amorphous material 50% Viscous secretions 30%  Mucosal agglutination  Stromal edema Tubal catheterization can be used both as diagnostic & therapeutic method Valle 1996Aboubakr Elnashar
  19. 19. The optimal contrast medium Oil-soluble Water-soluble Uterine image Sharp Less sharp Ampullary rugae Difficult to define Easier to define Viscosity Viscous Less viscous Absorption Months hours Pain Minimal Significant Granuloma formation Rare Very rare Embolism Rare anaphylaxis No major sequalae Pregnancy after HSG Doubled No effect Aboubakr Elnashar
  20. 20. Mechanisms by which HSG may enhance fertility 1. Mechanical lavage of a partially obstructed tube, 2. Stimulation of the tubal cilia 3. Inhibition of hostile peritoneal fluid immune cells Although oily media are now rarely used, there may be a place for it in the treatment of unexplained infertility (Steiner et al,2003) Aboubakr Elnashar
  21. 21. Contraindications Absolute Possible pregnancy History of acute PID. Relative History suggestive of PID Recent uterine instrumentation, Iodine allergy. Aboubakr Elnashar
  22. 22. The risk for PID after HSG 1% to 3% Routine antibiotic prophylaxis Patients at risk for acute PID Doxycycline: 100 mg twice a day for 3 days for all patients. Prophylactic antibiotics before uterine instrumentation if screening for CT has not been carried out. (NICE, 2013) Aboubakr Elnashar
  23. 23. 2. Sonohysterosalpingography An ultrasound contrast dye or saline (10-40 ml) is injected into the uterus through the cervix by a Foley catheter & the passage of the dye is followed by TVS. 76% concordance rate with laparoscopy dye The addition of pulsed wave or color Doppler imaging may improve the predictive value of transvaginal sonosalpingography experience effective alternative to HSG (NICE, 2013) Aboubakr Elnashar
  24. 24. HS-contrast-US Free fluid collection in the cul-de-sac following successful demonstration of oviductal patency. Oviductal fimbria are clearly observed in the collected fluid. Aboubakr Elnashar
  25. 25. Hydrosalpinx well-constrained fluid accumulation in the adnexae. In some cases, adhesions between the oviduct and ovary may be visualized. Aboubakr Elnashar
  26. 26. 3. Laparoscopy Indication 1. Abnormal HSG or 2.History or symptoms suggestive of pelvic disease. Normal HSG or no history suggestive of tubal disease: probability of clinically relevant tubal disease or endometriosis is very low: laparoscopy is not justified or cost effective (Fatum et al, 2002). Aboubakr Elnashar
  27. 27. Laparoscopy may reveal minimal or mild endometriosis or peritubal adhesions. Surgery or medical treatment has not been proven to improve fecunditity. With the current success rates of ART& the relatively low contribution of diagnostic laparoscopy to the decision making of treating patients with normal HSG, laparoscopy should be omitted in couples with unexplained infertility. These patients should be treated as UI (by 3 cycles of combined gonadotropins & IUI & if unsuccessful ART) Aboubakr Elnashar
  28. 28. Advantage 1. Direct visualization of the pelvic anatomy. 2. Determine: appearance of the fimbria presence of periadnexal adhesions endometriosis. 3. Correct timing will enable evidence of ovulation to be obtained. 4. No exposure to radiation 5. Can be combined with salpingoscopy &/or hysteroscopy. 6. Adhesiolysis or tubal constructive surgery can be performed. Aboubakr Elnashar
  29. 29. Laparoscopic findings: 1. Postinfection tubal disease . The most common Pelvic adhesions, phimotic fimbria, hydrosalpinges, or tubal obstruction. 2. Endometriosis 2nd most common An extremely variable (5% to 60%) Laparoscopic visualization, biopsy, or both are required for the diagnosis of endometriosis because there are no specific screening tests. 3. Isolated proximal occlusion 10% to 20% of tubal factor infertility. Aboubakr Elnashar
  30. 30. Aboubakr Elnashar
  31. 31.  ASRM classifications of adnexal adhesions, distal tubal occlusion, and endometriosis is based on laparoscopic findings and provides a rational foundation for therapy Aboubakr Elnashar
  32. 32. Disadvantages 1. An invasive test requiring a GA with its associated risk 2. Small risk of visceral damage on insertion 3. Not always possible to determine the actual site of occlusion. Aboubakr Elnashar
  33. 33. Hysteroscopy Not an initial investigation unless clinically indicated {effectiveness of surgical treatment of uterine abnormalities on improving pregnancy rates has not been established}. (NICE, 2013) Aboubakr Elnashar
  34. 34. 4. Transvaginal hydrolaparoscopy (THL) ±Method of choice for the clarification of mechanical infertility factors in symptom free patients with no suspicion of pelvic pathologies (Nawroth et al,2001). THL in association with minihysteroscopy provide more information & is better tolerated than HSG in outpatient infertility investigation Aboubakr Elnashar
  35. 35. 5. Chlamydia antibody testing (CAT) HSG is more accurate than CAT in predicting tubal disease (Elnashar et al,2000). If both tests were negative the tubal disease was identified on laparoscopy in only 4 % of case. Aboubakr Elnashar
  36. 36. Aboubakr Elnashar
  37. 37. Management strategy The role of surgery (open laparotomy or extensive laparoscopic surgery) for the treatment of tubal factor is shrinking (Aboulghar, 2003). Laparoscopic surgery has a role in peritubal adhesions Open laparotomy is only indicated in reversal of sterilization (ESHRE,2001). Aboubakr Elnashar
  38. 38. IVF Main player for treatment of tubal factor. Indication 1. Moderate to severe tubal disease A. Distal tubal occlusion with hydrosalpiges >1.5 cm in diameter. B. Distortion of the intraluminal architecture or endotubal adhesions detected by HSG, salpingoscopy or falloscopy 2. Other factors A. Sperm dysfunction B. Age >36 yr Aboubakr Elnashar
  39. 39. •Post-ligation: open microsurgery •Distal Tubal disease: Mild: Laparoscopic surgery Moderate to severe: IVF •Proximal tubal disease: Tubal catheterization •Distal & proximal tubal disease: IVF •If pregnancy has not occurred within 12 mo of surgery: IVF Aboubakr Elnashar
  40. 40. British Fertility Society Classification of Tubal disease Minor Proximal occlusion without tubal fibrosis Distal occlusion without tubal distension Healthy mucosal appearance at HSG, salpingoscopy flimsy peritubal/ovarian adhesions. Intermediat e Unilateral severe tubal damage Limited dense adhesions of tubes & ovaries Severe Bilateral severe tubal damage Extensive tubal fibrosis Tubal distension >1.5 cm Abnormal mucosal appearance Bipolar occlusion Extensive dense adhesion Aboubakr Elnashar
  41. 41. Aboubakr Elnashar
  42. 42. Peritubal adhesions with healthy endosalpinx •Laparoscopic surgery •IVF Chronic salpingitis • IVF • Salpingectomy before IVF in hydrosalpinx Post ligation Open microsurgery Management of tubal factor Aboubakr Elnashar
  43. 43. 1. Laparoscopic Surgery: Fimbrioplasty Lysis of fimbrial adhesions or the dilation of fimbrial strictures. Neosalpingostomy Creation of a new opening in a fallopian tube with a distal occlusion. Adhesiolysis more likely to work in the presence of patent tubes & filmy adhesions Aboubakr Elnashar
  44. 44. Aboubakr Elnashar
  45. 45. Aboubakr Elnashar
  46. 46. 2. Transcervical cannulation of the proximal fallopian tube Methods hysteroscopy fluoroscopy, or sonography Results successful catheterization 80% to 90% cumulative pregnancy 23% and 39% within the first 6 to 12 months. Ectopic pregnancy 5% to 13% Aboubakr Elnashar
  47. 47. Selective salpingography plus tubal catheterisation, or hysteroscopic tubal cannulation Proximal tubal disease If pregnancy has not occurred within 12 mo of surgery: IVF Aboubakr Elnashar
  48. 48. 3. Microsurgical reanastomosis of the fallopian tubes:  Patients who want to become pregnant after having undergone tubal sterilization may be candidates for tubal ligation reversal. Although tubal ligation reversal has traditionally been performed by laparotomy, recent studies suggest that laparoscopic surgical reanastomosis may be associated with comparable rates of success Aboubakr Elnashar
  49. 49. 4. In Vitro Fertilization Indications 1. Tubal factor infertility, 2. male factor infertility, 3. endometriosis 4. unexplained infertility. 5. IVF is recommended for all conditions that have not been successfully treated with other treatment strategies. Aboubakr Elnashar
  50. 50. IVF or ICSI: IVF should be the initial treatment of choice (Aboulghar et al,1996; Bukulmez et al,2000). {No significant difference in PR. or take-home baby}. Aboubakr Elnashar
  51. 51. Bilateral salpingectomy or tubal sterilization for women undergoing IVF who have 1. Hydrosalpinges, which adversely affect implantation rates during IVF, because of antegrade flow of noxious fluid. 2. Tubal damage and history of ectopic pregnancy because of the increased risk of a further ectopic pregnancy. Aboubakr Elnashar
  52. 52. Hydrosalpinges salpingectomy, preferably by laparoscopy, before IVF treatment {improves the chance of a live birth}. Aboubakr Elnashar
  53. 53. Benha University Hospital, Egypt Email:elnashar53@hotmail.com Aboubakr Elnashar

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